Kids in crisis are showing up younger and with behavioral problems more severe than in the past.

Once or twice a week something would set him off. Teachers often didn’t know why. His principal isn’t sure the little boy even knew. But suddenly he would explode — hitting, kicking, biting, trying to run away, tearing apart the classroom.

He was one of the youngest children in the Auburn elementary school, and he was out of control.

“There were a bunch of times that I was called and dealt with the student,” said Laura Shaw, Sherwood Heights Elementary School principal and a member of the school’s internal crisis response team. “And I remember just having him in my lap and he didn’t even know what he was angry about. Just sweating. Body was tight, tight, tight, tight …  And I’m not even doing a (restraining) hold. He’s still mad, but I’m not holding him. I’m feeling his body just gradually let go. And, honestly, I think it was something so small. You know, maybe he wasn’t first in line or something.”

Twenty years ago, experts say, it would have been unusual to be so young, so angry, so out of control so often. Teenagers can be destructive and difficult to manage sometimes, yes. But a first-grader? A kindergartner? A preschooler?

They’re seeing it now.

School leaders and mental health experts say Maine children are coming to them more often, at younger ages and with more significant problems than in decades past. Troubled teens have been joined by kindergartners in crisis.

“There are more extremes in behaviors than we’ve dealt with before,” said Lewiston school Superintendent Bill Webster.

Schools are working on programs that leaders hope will help. Because young children, like that raging little boy, don’t stay young for long.

“I remember thinking, ‘OK, he’s so little. What’s he going to do when he’s bigger?'” Shaw said.

Disruptive and dangerous

It’s difficult to gauge how many Maine children have severe behavior problems or have experienced immediate crises.

The percentage of Maine children who needed treatment or counseling for emotional, developmental or behavioral problems rose from 7.2 percent in 2007 to 10 percent in 2011, according to The National Survey of Children’s Health, provided by Maine Kids Count. However, the survey is done only every four years, so no more recent data is available.

Schools don’t have to track out-of-control children or notify the state about an incident unless the student had to be restrained or confined and secluded, according to the Maine Department of Education. Children who calm down without restraint or seclusion — such as the little boy at Sherwood Heights — don’t show up in the state count. Neither do the kids who were so explosive they couldn’t be restrained or confined and police had to be called.

Police track 911 calls about “children troubles,” but those calls include all school, parent and community complaints involving young people, whether it’s a child playing in the street or a child in a destructive rage. And sometimes the call isn’t a true police matter.

“Once in a great while, we’ll have a call where the child refuses to get out of bed and go to school,” said Auburn Deputy Chief Jason Moen. 

But while overall numbers are hard to find, many educators and child mental health experts say they deal with children’s severe behavioral issues every day and they’ve seen a shift in recent years: more girls in crisis, more severe behavior and more children out of control at 5, 6 or 7 years old rather than at 13, 14 or 15.   

“We’re having a fairly high rate of particularly younger students, those K, 1 and 2 kiddos, who are coming to us really having difficulty regulating their emotions, coping with frustration,” said James Cliffe, principal of Montello Elementary School in Lewiston. “And that manifests itself in some really disruptive and dangerous behaviors.” 

For one child, that could mean screaming and pitching a fit. For another, throwing things. For another, punching or biting.

Because major transitions can be difficult for children, behavioral problems tend to increase at the beginning of the summer, when school lets out, and at the end of the summer, when school resumes.

When a child is out of control at school, educators have options based on their school’s rules and school system’s policies. Typically, they first try to calm the child, usually through redirection, reason, restraint or seclusion. If that doesn’t work, they call the child’s parents. If parents don’t respond, or if the child is a danger, they call police.

“It is not uncommon, unfortunately, for us to call the police,” said Webster, who estimated the Lewiston school system calls for help at least once a month.

Police have their own options: find the child’s parents, try to calm the child themselves or get the child to a hospital, either in the back of a police car or an ambulance.

When a child is out of control at home and can’t be calmed, parents sometimes call police or Tri-County Mental Health Service’s statewide crisis hot line, which sends someone to evaluate the situation and suggest services or a trip to the hospital.

Tri-County’s crisis team sees 60 to 70 children per month from Androscoggin County and Bridgton Hospital. That’s an average of two kids in crisis per day.

Laurie Cyr-Martel, crisis services manager for Tri-County, hasn’t seen her cases skew younger in the past several years — she’s always encountered 7-year-olds in crisis as well as 17-year-olds. But she’s seeing more severe behaviors more often, including fire-setting, aggression and self-cutting or burning.

Sometimes she refuses to let her crisis workers go to a scene alone, even when a call comes through Tri-County’s hot line, because she’s concerned about their safety. 

“I’m not going to send my crisis team into a home where a 10-year-old is throwing knives and (has) just cut off the tail of a cat with a pair of scissors,” she said.   

Instead, she calls police and asks for an officer who has been specially trained in crisis intervention to meet them at the scene.

No one knows exactly why schools and mental health workers are seeing younger children and more severe behavioral problems.

Some say increases in disorders, such as autism, play a role  Some believe children aren’t learning how to deal with conflict or handle frustration as toddlers and preschoolers, so they lose control when they enter school and suddenly must navigate life with rules and other children. Others believe trauma, drug abuse by parents, societal changes or increases in family stress have caused children to act out more.

“I do think kids are different,” Webster said. “We’re being challenged in ways we traditionally were not challenged in schools. But it’s also a community issue. It’s more than a school issue. Schools are the way we tend to try to address these problems.”

Help

As kids show up younger or with more severe behavioral problems, schools and mental health organizations are scrambling to come up with ways to deal with them.

Caseworkers, social workers and community mental health professionals have joined traditional guidance counselors in many elementary schools. School resource officers — employed by local police departments — are now as connected to elementary schools as they are middle and high schools.

Lewiston four years ago piloted a program called Positive Behavioral Interventions and Supports and implemented it system-wide three years ago. The national program uses a tiered approach to behavioral problems — emphasizing prevention with clear expectations and positive reinforcement first, then a check-in, check-out system to keep an adult connection with more troubled students. The school system hopes this coming school year to do more with the third tier of the program, which is geared toward the most challenging kids. That tier evaluates a student’s triggers and creates an individual plan.

At Montello Elementary School, Lewiston’s second-largest elementary school, there’s also a Response to Intervention program, which provides assessment and intense, short-term help for students with behavior problems by teaching them new coping strategies. Midway through this school year, Montello also created a special, self-contained classroom for its youngest students with severe behavioral problems.  

“We focused on younger kids, thinking if we could get the behavior reshaped in K, 1 and 2, we’ll set them up for more success in the later grades,” said Cliffe, the principal. “I can say, anecdotally, I have five kids in that classroom right now who, at least three of them, I believe, would already be in the day treatment center by now if we hadn’t done this. They’ve been very successful … not blowing out of a classroom every day, not ending up in restraint, not being physically aggressive toward staff and peers, not having teachers throw their hands up and say, ‘I don’t know what to do next.'”

Auburn schools also work to head off crisis situations with a mix of programs and counselors. Sherwood Heights, which houses the school system’s elementary behavioral programs, maintains two special behavior classrooms and plans to add a third next school year. The school has one school counselor, one case manager and three private counselors, and it shares two police officers with the city’s five other elementary schools. 

“However, some kids, for whatever reason, do escalate and escalate rather quickly,” said Shaw, the principal. 

Every school has its own crisis-intervention team with a handful of staff members trained to address students’ out-of-control behavior, either by calming them down or moving them. At Sherwood Heights, those students might be moved to one of two “time-out” rooms, one of which has padding. The other has bare walls.   

“So they can yell, scream, spit, whatever,” Shaw said. 

If none of the school interventions works — or the child isn’t at school when he or she loses control —  Tri-County’s crisis team may get involved. But their help is limited to evaluation and recommendations for more long-term help.

“The crisis counselors aren’t there to do therapy,” said Cyr-Martel at Tri-County. “We are there to define what the risk is. What’s the reason that this child, preteen adolescent came to us in crisis, quote-unquote ‘out of control,’ if that’s what it was. And what was the precipitant? Why is it happening now?”

For some children, the next step is the ER.

Waiting for help

While schools are ramping up programs, more serious psychiatric help can be hard to get.

St. Mary’s Regional Medical Center in Lewiston has one of the few inpatient psychiatric units for children in Maine, and the hospital is known for its mental health services, so it’s not unusual for children in crisis to end up there in an emergency. 

A few years ago, St. Mary’s redesigned its ER to accommodate them.

“Back before (the redesign), they had sort of cordoned off one little corner of the emergency room and called it the ‘behavioral area.’ It was literally a corner. You could have a 60-year-old alcoholic drunk guy right next to the 7-year-old in crisis. It was horrible,” said Dr. Michael E. Kelley, chief medical officer for behavioral health. “So we created completely separate areas.”

St. Mary’s now maintains two ERs, one for medical emergencies and one for mental health emergencies. The mental health section has a separate area for children, with two exam rooms and a central lounge with child-sized furniture. It’s monitored by psychiatric nurse practitioners who can evaluate children, diagnose problems and make decisions about medication. The hospital’s child psychiatrists are available for consultations. 

The ER is supposed to be used for immediate stabilization and diagnosis only, but children can be there much longer. The problem: a lack of inpatient hospital beds for kids in crisis. 

“The ideal may be four to five hours (waiting in the ER),” Cyr-Martel said. “In reality you’re talking probably two to seven days. The outliers, we’ve had kids there longer.”

Kids in the ER sleep in the exam-room beds. If those are full, they sleep on a couch in the children’s lounge area.

Not all children have to be hospitalized, even if the crisis landed them in the ER. Some can be stabilized and sent home with a plan to follow up with their doctors and therapists. Others can enroll in an intensive outpatient program, allowing them to get several weeks of therapy, medication management and other help without staying overnight.

But some children need the help and safety of hospitalization. In Maine, only a few inpatient behavioral units take children. If insurance approves, children can go out of state to a hospital.

St. Mary’s inpatient unit for 5- to 18-year-olds is geared to short-term stays of seven to 10 days, but — like the ER — that doesn’t always happen.

As children in the ER can wait days for a bed to open up in the hospital, children in the hospital can wait weeks, or longer, for a bed to open up in a residential treatment program.

“We have patients who do stay with us up to three months awaiting placement because there’s not a safe alternative in the interim,” said Ruth Hall, director of child and adolescent services for St. Mary’s.

Maine has 11 residential treatment providers with a total of 387 beds for children. Even when there are empty beds — more than 70 were available last week, according to the state — kids may wait because the available program doesn’t have the right clinical focus, is too far away for parents’ comfort or is limited to children with specific problems.

Liam Shaw manages one of those residential programs — Community Health and Counseling Services’ multidimensional treatment program. It places kids 12 to 17 years old in homes with adults specially trained to deal with kids who are violent, defiant, angry, have mental illnesses or are abusing drugs.

Although it’s a few years old and has a good reputation, the program only has five homes, enough for only five children. It could fill at least 20 beds if it had them, Shaw said, but it’s had trouble recruiting people to run homes.

“We’re dealing with kids who come to us with more on their plate than they used to. Certainly younger kids. More girls, as well,” Shaw said. “The nice thing about this program is we’ve been able to take some kids that, on paper, would be kind of a little scary, and really work with them and see some nice results.”

This week, four of its five homes were filled.

Some experts believe the lack of long-term help is adding to the problem of kids in crisis.

“There’s less of the group homes, less of the crisis centers, less places for difficult-to-manage kids to be managed,” Kelley said. “Probably some of it was also very well-meaning: Let’s get them back in the home instead of sticking them in group homes. But, unfortunately, that means parents who used to be able to get a kid to a boarding school for mentally handicapped kids or something is trying to manage these very difficult kids in their own homes.”  

Experts say the search for treatment can be hard on families that are already overwhelmed by a child’s needs, whether that treatment is a special behavioral room at school or a long-term residential treatment program. Their advice: Be persistent. Be patient. Don’t be afraid to advocate for your child.

“It’s a matter of finding what works. It really is tough,” said Jon Normand, senior program director for education at Spurwink, which provides mental health and educational services to children and adults across the state.

“For some kids, they’ll spend the better part of a decade finding what works,” he said. “For others, fortunately, they’ll find it right away.”

ltice@sunjournal.com

Resources for parents:

Statewide crisis hotline: 1-888-568-1112

Tri-County Mental Health Services Mobile Crisis Outreach: 783-4680

Information on resources and services statewide: Call 211 or visit www.211maine.org

State services for children with behavioral issues: 1-800-432-7366 or http://www.maine.gov/dhhs/ocfs/cbhs/index.shtml

Child Development Services (help for children birth to 5 with special needs): 1- 877-770-8883 or http://www.maine.gov/doe/cds/

New Beginnings (family crisis and conflict mediation, shelter for youths ages 12 to 20): 795-4070

Parent support group for RSU 16 (newly forming): annhemond@gmail.com

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